SHOULDER IMPINGEMENT SYNDROME

INTRODUCTION The term “Impingement Syndrome” was popularized by Charles Neer in 1972 • Neer defined impingement as pathologically compression of rotator cuff against the anterior structure of coracoacromial arch, anterior 1/3 of the acromion, coraco-acromial ligament & AC joint. • Progression of syndrome is define by a narrowing of the sub-acromial outlet by spur formation in coracoacromial ligament & undersurface.

• Impingement causes Mechanical irritation of cuff tendons - resulting in haemorrhage and swelling (commonly known as tendonitis of rotator cuff) – The supraspinatus muscle is usually involved. • This also affect the bursa – resulting in bursitis. • Shoulder complex is susceptible to impingement injuries from overhead sports – Such as baseball, tennis, swimming, volleyball etc. • Impingement with rotator-cuff tendonitis is one of most common shoulder injuries seen in athletes.

SIGNS & SYMPTOMS Pain & tenderness in the gleno-humeral area • Pain or weakness with active abd. in midrange • Limited internal rotation compared to normal side • Confirmation with special tests (Hawkins impingement test) • Tenderness to palpation in the sub-acromial area

TYPES OF IMPINGEMENT (site) *Subacromial/External impingement: A mechanical encroachment of soft tissue structures as bursa and rotator cuff tendons between humeral head and acromial arch. Pain in midrange of abduction leading to painful arc.

TYPES OF IMPINGEMENT *Internal impingement: Encroachment of rotator cuff tendons between humeral head and glenoid rim.

TYPES OF INTERNAL IMPINGEMENT 1. Anterosuperior glenoid impingement: Entrapment of subscapularis retract after deep surface tears. Pain provoked at shoulder flexion and internal rotation 2. Posterosuperior glenoid impingement: Encroachment of supraspinatus tendon between greater tubercle of humerus and posterosuperior glenoid rim. Pain provoked at maximal external rotation, horizontal abduction and abduction.

PRIMARY &SECONDARY IMP. (cause) Pain caused by structural narrowing of subacromial space due to: -AC arthropathy -Type I/III acromion -Swelling of soft tissue within the subacromial space.

PRIMARY &SECONDARY IMP. *2nd Imp.: No structural abnormalities, functional problems in specific positions In subacromial space. Internally in glenohumeral joint.

Factor development of External impingement Anatomical abnormalities – e.g. beaked/ # acromion, osteophytes • Poor scapular control • Anterior instability • Postural changes in upper quadrant – Forward head & rounded shoulder posture

Types of acromions

Factor development of internal impingement • Overuse – repetitive trauma • Loose joint • Instability • Muscle imbalance • Superior labrum injury

Stages of Shoulder Impingement Syndrome (SIS) *Stage I: (edema & inflammation) • Age – younger than 25 years (but may occur at any age) • Reversible lesion • Tenderness over greater tuberosity of humerus • Tenderness over anterior ridge of acromion • Painful arch 60 – 120 • (+) ve Neer impingement test • ROM may restricted with sub-acromial inflammation

Stages of Shoulder Impingement Syndrome (SIS) *Stage II: (fibrosis & tendinitis) • Age – 25 – 40 years • Not reversible by modification of activities • Stage I signs + the following : – Soft tissue crepitus – Catching sensation at lowering arm (approx 100) – Limitation of active & passive ROM

Stages of Shoulder Impingement Syndrome (SIS) *Stage III: (bone spur & tendon rupture) • Age > 40 years • Not reversible • Stage I + II signs + following : – Limited ROM more prominently – Atrophy of infra-spinatus – Weakness of abductor & external rotator – Bicep tendon involvement – AC joint tenderness

SPECIAL TESTS • For impingement : – Neer impingement test – Hawkins impingement test • Rotator cuff test : – Supraspinatus – empty can – Subscapularis – Lift off – Drop arm – for full thickness rotator cuff

Treatment Goals To relieve pain & swelling • To retard muscle atrophy & strengthen cuff muscle • To maintain & improve ROM • To increase strength, endurance & power

Treatment Oral anti-inflammatory medication Cryotherapy: -Over the tender area in early inflammation stage -Duration – 10 – 15 min -Greater effect along with medication. Electrotherapy: - TENS is useful in controlling pain - US therapy with 0.8 w/cm2, 3MHz, 6 min – to decrease inflammation - Other modalities like LASER, IF are also effective in pain control

Bio feed back: - It may be appropriate if there is excessive laxity of humeral head. -Helpful in athlete unable to gain control of the rotator cuff musculature Manual therapy approach: *Mobilization for GH : -Grade I & II in early stage - As symptoms response, can shift to even grade III & IV

Therapeutic exercise Pendular exercises with light weight (1kg or Less) Active assisted ROM exercises in pain free range e.g. Rope & Pulley Capsular stretching Stretching of upper trapezius, pectorals, biceps. Towel exercise.

Strengthening exercises: – Isometric exercises : – Scapular stabilization exercises. - Strengthening using theraband. - Plyometric exercises. – Isokinetic exercises.

Surgery: -Arthroscopic subacromial decompression - Capsulorrhaphy

Preventing Re-injury: • Perform warming-up before & cooling-down after training, for no less than 15 minutes. • Including stretching ex’s for the shoulder muscles and capsule. • Perform strengthening exercises for the shoulder twice a week. • Ensure you take adequate rest & avoid playing too many games in too short period. • Fatigue plays an important role in occurrence of this kind of injury.

SHOULDER INSTABILITY

Introduction • Highest mobility, at the expense of stability • Most frequently dislocated -50 % of all dislocations -2 % incidence in general population • Factors predisposing to recurrent dislocation -Age -Return to contact sports -Hyper-laxity -Significant Bony defect in glenoid or humeral head

What is instability? Inability to maintain the humeral head centered in the glenoid fossa and coracoacromial arch throughout ROM. • Instability ≠ Joint laxity • Laxity = Incomplete loss of glenohumeral articulation unassociated with pain • Subluxation = Partial loss of glenohumeral articulation with symptoms • Dislocation = Complete loss of glenohumeral articulation

Functional Anatomy

Gleno-humeral Stability Static restraints -Gleno-humeral ligaments -Glenoid labrum -Articular congruity & version. -Negative intraarticular pressure Dynamic restraints -Rotator cuff muscles -Rotator cuff interval -Biceps long head -Peri-scapular muscles

Static restraints

Dynamic restraints

Physical examination • Atrophy or asymmetry around shoulder • Tenderness around anterior or posterior capsule • Active and passive ROM • Strengths of the deltoid, rotator cuff and scapular stabilizers. • Special tests: -Shift and load test -Sulcus test -Apprehension test

TREATMENT *ANTERIOR DISLOCATION 97% of recurrent dislocation abduction, extension and external rotation Subcoracoid subglenoid subclavicular Associated Injuries: Fractures of Head & Neck Rotator Cuff Tears

TREATMENT *NONOPERATIVE Closed Reduction Immobilization-Sling Analgesics Rehabilitation

TREATMENT OF RECURRENT ANT. DISLOCATION *Non-operative ttt: Only 16% traumatic respond 80% atraumatic respond Poor response to non operative ttt *Surgical stabilization: Open or arthroscopic

OPERATIVE TREATMENT *Capsulolabral Repair - Bankart - Modified Bankart *Subscapularis Procedures - Putti-Platt - Magnuson-Stack *Coracoid Transfer Procedures - Bristow - Latarjet

POSTERIOR DISLOCATION Incidence: < 5% of all shoulder dislocations 3% of recurrent

Mechanism of injury: - Axial load - Flexed/Adduction -Swimming -Rowing -Football Offensive Lineman

TREATMENT Non Operative -Immobilization - Rehabilitation - 70-90% improve - Functional disability improved - Instability not eliminated

Operative Management -Overall 50-95 % success *Soft Tissue Procedures - Posterior Capsulorrhaphy -Reverse Putti-Platt *Bone Procedures - Posterior Glenoid Osteotomy -Posterior Bone Block

REHABILITATION *Phase I (Post op to 3 weeks) Rest and immobilization. Pain control with nonsteroidal anti-inflammatory drugs and ice applied to the shoulder. No ext rotation Abduction less than 45° *Phase II (3 to 6 weeks) Isometric strengthening, Isotonic strengthening. Begin exercises with shoulder in adducted, forward- flexed position, progressing to abducted position. Resistive exercises.

REHABILITATION *Phase III ( 6 weeks to 3 months) Endurance building along with strengthening exercises. Goal: the patient reaches 90% strength in the injured shoulder compared with the uninjured shoulder. Non contact = 6 weeks *Phase IV (3 months to 6 months) Increase activity to sport- or job-specific activities contact = 12 weeks